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BACKGROUND Digital smoking cessation interventions can include a wide range of specific elements which range in intensity, duration, efficacy, attractiveness, and level of active involvement required from the user. Little is known regarding the extent to which the likelihood of engagement in a specific intervention element varies with either (a) level of intensity/implicit demand for active involvement, or (b) presentation alone vs. together with one or more alternative options. Motivational approaches suggest that providing alternative options will facilitate engagement in at least one of them, whereas choice overload theory suggests that more options could inhibit engagement. OBJECTIVE To evaluate the likelihood of engagement in a digital intervention element as a function of (a) intervention intensity and (b) provision alone vs. with a second option. METHODS Secondary analysis of a factorial trial involving 85 pregnant adult smokers. This analysis focused on six conditions in which participants were offered the opportunity to click to learn more about either one or two of three discrete options (brief video, SmokefreeMOM text messaging, and the Michigan Smoking Cessation Quitline) ranging in level of intensity and active involvement required. Analyses focused on main effects of intensity and choice as well as on their interaction. RESULTS The likelihood of clicking on any single option did not vary with the intensity of the option offered (with click rates ranging from 85.7% to 92.9%), or with number of options offered (among participants given a single option, 90.5% clicked to proceed with one of them, vs. 76.7% of participants given two options; χ2 [2] = 2.9, p = .088). However, there was an interaction between intensity and number of choices, such that 85.7% of participants chose the Quitline when it was the only resource offered, but only 10.7% of participants did so when it was offered along with another option (χ2 [1] = 22.87, p < .001). CONCLUSIONS These formative analyses did not identify a significant difference in digital intervention engagement as a function of either intervention intensity or number of options offered. However, the most demanding (and best validated) option of working with a Quitline coach was clicked by nearly all participants when it was the only choice available, and by almost none when it was accompanied by a less intensive alternative. Further research is needed on whether and when providing only a single option may promote engagement with smoking cessation resources, with particular attention to whether more intensive options should be offered alone rather than alongside less demanding alternatives.

HBB-related significant hemoglobinopathies have been anecdotally associated with low fetal fraction on noninvasive prenatal screening (NIPS). We sought to compare the difference in fetal fraction u...

Background Alcohol use during pregnancy can have a variety of harmful consequences on the fetus. Lifelong effects include growth restriction, characteristic facial anomalies, and neurobehavioral dysfunction. This range of effects is known as fetal alcohol spectrum disorders (FASD). There is no amount, pattern, or timing of alcohol use during pregnancy proven safe for a developing embryo or fetus. Therefore, it is important to screen patients for alcohol use, inform them about alcohol's potential effects during pregnancy, encourage abstinence, and refer for intervention if necessary. However, how and how often nurses and midwives inquire about alcohol drinking during pregnancy or use recommended screening tools and barriers they perceive to alcohol screening has not been well established. Methods This survey was sent to about 6,000 American midwives, nurse practitioners, and nurses who provide prenatal care about their knowledge of the effects of prenatal alcohol exposure, the prevalence of alcohol use during pregnancy, and practices for screening patients' alcohol use. Participants were recruited by e-mail from the entire membership roster of the American College of Nurse-Midwives. Results There were 578 valid surveys returned (about 9.6%). Analyses showed that 37.7% of the respondents believe drinking alcohol is safe during at least one trimester of pregnancy. Only 35.2% of respondents reported screening to assess patient alcohol use. Only 23.3% reported using a specific screening tool, and few of those were validated screens recommended for use in pregnant women. Respondents who believe alcohol is safe at some point in pregnancy were significantly less likely to screen their patients. Conclusions Respondents who reported that pregnancy alcohol use is unsafe felt more prepared to educate and intervene with patients regarding alcohol use during pregnancy and FASD than respondents who reported drinking in pregnancy was safe. Perceived alcohol safety and perceived barriers to screening appeared to influence screening practices. Improving prenatal care provider knowledge about the effects of prenatal alcohol exposure and the availability of valid alcohol screening tools will improve detection of drinking during pregnancy, provide more opportunities for meaningful intervention, and ultimately reduce the incidence of FASD.

The maternal mortality ratio in the United States is increasing; understanding the significance of this change and developing effective responses requires a granular analysis of the contributing factors that a well-informed maternal mortality review committee can provide. Data collection and analysis, clinical factors, preventability, social determinants of health, and racial inequities combine to affect this outcome, and each factor must be considered individually and in combination to recommend a robust response. Obstetrician-gynecologists formed the State of Michigan's Maternal Mortality Review Committee (the Committee) in 1950 to identify gaps in care that needed to be systematically addressed at the time. In the early years, the Committee witnessed a reduction in the number of maternal deaths; over time, prioritization of maternal mortality decreased, yet the Committee witnessed changing patterns of death, varied data collection and evaluation processes, delayed reviews, and unimplemented recommendations. The calculation of the maternal mortality ratio was not informed by the outcomes of Committee reviews. Today, the Committee, with increased support from the Michigan Department of Health & Human Services, can clearly identify and report preventable pregnancy-related mortality along with its causes and is close to achieving a near real-time surveillance system that allows the development of timely clinical and policy recommendations and interventions. The Committee's adaptations in response to the rise in maternal mortality have resulted in several lessons learned that may be helpful for currently operating committees and in the formation of new ones.

The outbreak of the SARS-CoV-2 elicited a surge in publications. Obstetric reports were with few exceptions characterized by small sample sizes with potentially limited generalizability. In this review, evidence suggests increased susceptibility to COVID-19 in pregnancy; common pregnancy comorbidities may help explain worse outcomes. While the risk of death is low, pregnancy may be associated with increased need for ventilation. Prematurity rates seem to be increased but may be accounted for in part by higher cesarean rates, to a large degree accounted for by elective decision to shorten the course of the labor. Though fetal/neonatal complication rates may be higher in the presence of COVID-19 infection, survival rates seem unaffected and vertical transmission is rare. As the outbreak continues in the USA with resurgence in many other western countries that achieved initial success in suppressing the virus, much remains to be learned. For example, the question related to the degree to pregnancy modifying symptomatology remains open. Currently, routine polymerase chain reaction testing remains limited by supply shortages possibly delaying diagnosis until later in the course of the disorder and thus altering the symptom complex at presentation. To add to the knowledge base, we initiated a regional COVID-19 in pregnancy collaborative observational study with a coordinating center, standardized data collection and a shared database. This was facilitated by a longstanding tradition of collaboration among regional obstetric services. Over an anticipated two-year study duration, we expect to study 400 documented and suspected COVID-19 pregnancies with time and site of services controls for cohort effect and high power to detect several adverse maternal/infant outcomes. We include a complete listing of variables in our database, which, along with our experience in setting up our regional collaborative, we hope and believe will be of use in other settings.

Women with systemic lupus erythematosus (SLE) are at increased risk for cervical neoplasia likely due to infection with high-risk human papillomavirus (HR-HPV) and should be considered for HPV vaccination. We sought to determine the frequency of HR-HPV infection and uptake of HPV vaccination in our regional female lupus population.For this medical records review study, data were analyzed from our electronic health records EPIC for women with International Classification of Diseases-10 or International Classification of Diseases -9 billing codes for SLE seen June 6, 2007, to May 1, 2017. This study was approved by the Central Michigan University/Covenant Medical Center institutional review board. Statistical analyses consisted of Student t test, χ, and Z test for proportions using SPSS v. 24 software.A total of 1349 women with SLE were identified, mean age of 53 years, 70.8% white, 20.8% African American, with 49% exposed to cigarette smoke. High-risk HPV testing performed in 195 (14.5%; mean age, 50 years) showed 16.9% (33/195) were positive, with those testing positive for HR-HPV being slightly younger (p0.05).Comparing our proportion testing positive for HR-HPV (0.169) versus National Health and Nutrition Examination Survey (0.088), we calculated a Z = 3.99 (p0.001) indicating HPV infection is significantly higher (2×) in our female SLE cohort. Only 16.0% (38/238) of the 238 women eligible to receive an HPV vaccine were tested for HR-HPV with 9 being positive and only 4.6% (11/238) vaccinated.Human papillomavirus infection is a serious health issue in women with SLE, but HPV testing and vaccination rates remain low. Efforts should be directed to promote awareness of the importance of HPV vaccination in this high-risk population.

This is a retrospective case-control study. Cases were women with a diagnosis of HSH using NIPS from a commercial laboratory. The comparison group was women with hemoglobin AA from a tertiary care center database. We tested for differences in median fetal fraction using quantile regression analysis, adjusting for maternal body weight and gestational age.This study includes 35 women with clinically significant HSH and a comparison group of 636 women with hemoglobin AA. Adjusting for gestational age and body weight, the median fetal fraction was 4.1 point lower in the HSH than in the comparison group (Women with HSH were more likely to have a lower fetal fraction and ultimately a five-fold higher no-call rate.

Even moderate alcohol consumption during pregnancy can pose risks to the fetus, making reliable and consistent detection of drinking in pregnancy critical. Ethyl glucuronide (EtG) and ethyl sulfate (EtS) have shown some ability to detect lower levels of drinking, but the sensitivity of commercial EtG/EtS testing to lower levels of drinking among women of childbearing age is unknown. This study sought to determine the ability of an EtG/EtS algorithm, as well as EtG alone, to detect alcohol consumption in women of childbearing age using commercial testing and cutoffs.Ten women (ages 21-39 years of age) were administered one, two, or three standard drinks in separate sessions. Urinary EtG/EtS was measured at baseline and again at five timed intervals for 72 hours following each session. Samples from the first five participants used a commercial algorithm in which a positive test was EtG100 ng/ml and EtS25 ng/ml; samples from the next five participants were considered positive if only EtG was100 ng/ml.All samples were positive at the 12-hour follow-up. By 24 hours, sensitivity for one standard drink was poor for the combined EtG/EtS assay as well as for EtG alone (20% detection) and modest for two standard drinks (40% detection). There were no positive EtG results after 36 hours.The EtG/EtS cutoffs used in the present study, which are representative of those used by commercial laboratories, were not sensitive enough to reliably detect light to moderate drinking beyond a 12-hour window among women of childbearing age.

In spite of several policies aiming to decrease cesarean rates and related complications such as uterine rupture, data show that uterine rupture and associated morbidity are increasing along the years. Whether previously unidentified risk factors are currently playing an important role on these trends is unknown. We analyze current risks of uterine rupture and main preceding factors from more recent years compared to former data. All uterine rupture cases in the US from 2011–2012 were selected, with matched non-uterine rupture cases selected as controls. Variables considered for analysis included demographics, maternal morbidity, and obstetric complications. Likelihood forward selection was used to identify main risk factors of uterine rupture. Medians of main factors identified were used to simulate groups at risk and calculate odds ratios of uterine rupture. From ~8 million births, 1925 presented uterine rupture. In patients with no prior cesarean delivery, multiple gestation, chronic hypertension and chorioamnionitis presented the highest odds of uterine rupture, with the combination of these factors increasing the odds of rupture 59 times (~1%). In women with prior cesarean delivery, induction/augmentation and chorioamnionitis were the most significant predictors, with the combination increasing the odds 33 times (~3%). Despite policies implemented and changes in clinical practice, uterine rupture remains an important issue. Previously unidentified risk factors are playing now an important role, information that should be considered during patient counseling and clinical practice. Combinations of some of these factors may increase the risk of uterine rupture significantly enough to modify clinical care.

Objective This study evaluated the safety and immunogenicity of qHPV vaccine in SLE. Methods Subjects: 34 women ages 19–50 years (yrs.) with mild to moderate SLE & minimally active or inactive SLE received qHPV vaccine at the standard dosing schedule. Exclusion criteria: active SLE disease (SELENA-SLEDAI > 2), history of severe SLE disease, deep venous thrombosis, on >400 mg/day of hydroxychloroquine, on >15 mg/day of prednisone, or active infections. Patients were monitored for adverse events (AE), SLE flare, generation of thrombogenic antibodies and thrombosis. Antibody (Ab) levels to HPV 6, 11, 16 & 18 were measured by HPV competitive Luminex Immunoassay and Geometric Mean Titers (GMTs) were calculated for each HPV type. Seroconversion was assessed for those seronegative at baseline. Results The women in the study: African-American (79%), mean age = 38.1 years, mean age at diagnosis of SLE = 28.6 years, 35.3% had a history of smoking, 91% had 4 or more sexual partners, 50% had a history of sexually transmitted diseases, and 27.3% used condoms on a regular basis. Vaccine site reactions (VSRs) occurred in 62%, all mild. Ninety-seven percent experienced at least 1 non vaccine adverse event (nvAE) with a total of 493 nvAEs in 33 patients, of which 90% were mild and none were related to vaccine or SLE. There were 9 serious AEs, none were related to vaccine or SLE, all resolved. No patient experienced an SLE flare, thrombosis, or generation of thrombogenic antibodies. Seroconversion rate was 100% with mean GMTs comparable to Gardasil® package insert data. Conclusion In this SLE vaccine study, qHPV vaccine was generally safe, well tolerated, and highly immunogenic. This clinical trial is registered on Clinical Trials.gov under number, NCT01741012 and was conducted under the FDA IND BB14113.

AIM Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture. METHODS Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χ2 test, and relative risks were calculated. Logistic regression was used to identify the most significant complications. P < 0.05 indicated statistical significance. RESULTS From 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold). CONCLUSIONS Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Objective American College of Cardiology and American Heart Association (ACC/AHA) published new guidelines which lower the cut-off for hypertension. We sought to evaluate the impact of these guidelines to cost and benefit of various low-dose aspirin prophylaxis approaches. Study Design Decision tree analysis was created using R software to evaluate four approaches to aspirin prophylaxis in the United States: no aspirin, United States Preventive Service Task Force (USPSTF) with Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines, USPSTF with ACC/AHA hypertension guidelines, as well as universal aspirin prophylaxis. This model was executed to simulate a hypothetical cohort of 4 million pregnant women in the United States. Results The new guidelines would expand the aspirin eligibility by 8% (76,953 women) in the USPSTF guidelines. Even with this increased eligibility, the USPSTF guidelines continue to be the approach with the most cost savings ($386.5 million) when compared with universal aspirin and no aspirin prophylaxis. The new hypertension guidelines are projected to increase the cost savings of the USPSTF approach by $9.4 million. Conclusion Despite the small change in aspirin prophylaxis, using ACC/AHA definition of hypertension still results in an annual cost-saving of $9.4 million in the United States when compared with JNC7.

African-American adolescents experience disproportionate rates of negative consequences of substance use despite using substances at average or below-average rates. Due to underrepresentation of African-American adolescents in etiological literature, risk and protective processes associated with their substance use require further study. This study examines the role of parental support in adolescents’ conduct problems (CPs), depressive symptoms (DSs), and alcohol and marijuana use in a national sample and a high-risk sample of African-American adolescents. In both samples, parental support was inversely related to adolescent CPs, DSs, and alcohol and marijuana use. CPs, but not DSs, partially mediated the relation of parental support to substance use. Results were consistent across the national and high-risk samples, suggesting that the protective effect of parental support applies to African-American adolescents from a range of demographic backgrounds.

Machine (learning)-based techniques have made substantial advances recently, and there is a general suggestion that they will drive major changes in health care within a few years. Yet, we all suffer from the lack of precise comparative studies on the accuracy of machine-based interpretations of medical data. To fill this gap, in this paper we investigate on the efficacy of using an automated mood analysis methodology to understand how patients react to the prescription to take different kinds of prenatal diagnostic tests (invasive vs non-invasive) and to the corresponding outcomes, based on conversations developed on Reddit. Our study essentially provides answers to research questions concerning: i) the popularity of prenatal diagnosis, ii) the patients' sentiment about different prenatal tests, iii) the existence of a cause-effect relationship between prenatal testing and patients' mood, and iv) the type of dialogues held by patients and physicians on this topic. Nonetheless, a general result emerging from our research is that a machine-based decision loop for now still needs human involvement, at least to alleviate the tension between empirical data and their correct medical interpretation.

The primary objective of this study is to evaluate the availability and duration of formal medical genetics and genomics (MGG) education during obstetrics and gynecology (OB/GYN) residency training in the United States compared to other noncore OB/GYN rotations.We performed a review of rotation schedules published in all American Council for Graduate Medical Education (ACGME)-accredited OB/GYN residency programs' websites during the month of December 2016. Information regarding availability and duration of MGG rotation and other noncore OB/GYN rotations (ultrasound, breast health, and family planning) were collected.Among 256 ACGME-accredited OB/GYN residency programs, rotation schedule was available for 238 (93%). Only 34 programs (14.3%) had some form of MGG rotations. In the GLM, when compared to other noncore OB/GYN rotations, the mean duration of MGG rotation was significantly less than ultrasound (0.07 versus 0.57 months, p .05) and family planning (0.07 versus 0.42 months, p .05). The number of residents was the only variable significantly correlated with the availability of an MGG rotation (OR 1.07, 95%CI 1.02-1.13).Despite the growing importance of MGG in day-to-day OB/GYN practice, only a limited number of ACGME-accredited OB/GYN residency programs offer an MGG rotation. When compared to other noncore OB/GYN rotations, such as, ultrasound and family planning, any MGG rotation was significantly shorter. With clear evidence that MGG will continue to radically change practice of OB/GYN in the future, it is imperative that steps need to be taken to address this deficiency in training.

Despite media reports and educators' concerns, little substantive data have been published to document or refute the emerging reports that children prenatally exposed to cocaine have serious behavioral problems in school. Recent pilot data from this institution have indeed demonstrated teacher-reported problem behaviors following prenatal cocaine exposure after controlling for the effects of prenatal alcohol use and cigarette exposure. Imperative in the study of prenatal exposure and child outcome is an acknowledgement of the influence of other control factors such as postnatal environment, secondary exposures, and parenting issues. We report preliminary evaluation from a large ongoing historical prospective study of prenatal cocaine exposure on school-age outcomes. The primary aim of this NIDA-funded study is to determine if a relationship exists between prenatal cocaine/alcohol exposures and school behavior and, if so, to determine if the relationship is characterized by a dose-response relationship. A secondary aim evaluates the relationship between prenatal cocaine/alcohol exposures and school achievement. Both relationships will be assessed in a black, urban sample of first grade students using multivariate statistical techniques for confounding as well as mediating and moderating prenatal and postnatal variables. A third aim is to evaluate the relationship between a general standardized classroom behavioral measure and a tool designed to tap the effects thought to be specific to prenatal cocaine exposure. This interdisciplinary research team can address these aims because of the existence of a unique, prospectively collected perinatal Database, funded in part by NIAAA and NICHD. The database includes repeated measures of cocaine, alcohol, and other substances for over 3,500 births since 1986. Information from this database is combined with information from the database of one of the largest public school systems in the nation. The final sample will be composed of over 600 first grade students for whom the independent variables, prenatal cocaine/alcohol exposures, were prospectively assessed and quantified at the university maternity center. After informed consent, the primary dependent variable, school behavior, is assessed, using the PROBS-14 (a teacher consensus developed instrument), the Child Behavior Check List, and the Conners' Teacher Rating Scale. The secondary dependent measure, school achievement, is measured by the Metropolitan Achievement Text and the Test of Early Reading Ability. Control variables, such as the environment and parenting, are measured by several instruments aimed at capturing the child and family ecology since birth. All analyses will be adjusted as appropriate for prospectively gathered control variables such as perinatal risk, neonatal risk, and other prenatal drug and cigarette exposures. Further adjustment will be made for postnatal social risk factors which may influence outcome. Of particular concern are characteristics of the home (adaptation of HOME), parent (depression, stress), and neighborhood (violence exposure). Finally, postnatal exposure to lead and other drugs is being considered.

Fetal alcohol spectrum disorder is common and associated with economic costs greater than comparable other childhood and adult disorders. We need to turn our attention to prevention and mitigation.

Prenatal Alcohol Exposure (PAE) can lead to life-long neurobehavioral and social problems that can include a greater likelihood of early use and/or abuse of alcohol compared to older teens and young adults without PAE. Basic research in animals demonstrates that PAE influences later postnatal responses to chemosensory cues (i.e., odor & taste) associated with alcohol. We hypothesized that PAE would be related to poorer abilities to identify odors of alcohol-containing beverages, and would alter perceived alcohol odor intensity and pleasantness. To address this hypothesis we examined responses to alcohol and other odors in a small sample of young adults with detailed prenatal histories of exposure to alcohol and other drugs. The key finding from our controlled analyses is that higher levels of PAE were related to higher relative ratings of pleasantness for alcohol odors. As far as we are aware, this is the first published study to report the influence of PAE on responses to alcohol beverage odors in young adults. These findings are consistent with the hypothesis that positive associations (i.e., “pleasantness”) to the chemosensory properties of alcohol (i.e., odor) are acquired prenatally and are retained for many years despite myriad interceding postnatal experiences. Alternate hypotheses may also be supported by the results. There are potential implications of altered alcohol odor responses for understanding individual differences in initiation of drinking, and alcohol seeking and high-risk alcohol-related behaviors in young adults.

To identify the optimal gestational age (GA) for induction of labor (IOL) at term among patients with gestational diabetes (GDMA) according to perinatal outcomes. The US Natality Database from 2007 to 2010 was reviewed. Inclusion criteria were singleton delivery, IOL at 37 to 42 weeks and GDMA. Exclusion criteria included congenital anomalies, pre-gestational diabetes, hypertensive disorders, previous cesarean, breech presentation and rupture of membranes. Controls were non-GDMA cases delivered in geographic and temporal proximity. Delivery mode, macrosomia and perinatal complications were analyzed. Logistic regression adjusted for confounders was used to calculate odds ratios by GA using 39 weeks non-GDMA as reference. In all, 96 964 cases and 176 079 controls were included. Increased risk for all adverse outcomes among GDMA cases was found. The nadir for intrapartum and neonatal complications was 38 and 40 weeks, respectively, whereas for cesarean and macrosomia was 39 weeks. The optimal timing for IOL at term in GDMA appears to be 39 to 40 weeks.

The recommendation for elective induction of labor (IOL) is to await ≥ 39 weeks. Studies show earlier maturity of Blacks compared to Whites. The objective was to examine the effect of the Black race on the risk of intrapartum and neonatal complications after IOL.Black women with non-indicated IOL at 37-42 weeks were selected from the CDC-Birth Cohorts 2007-2010. Congenital anomalies, hypertension/diabetes, low-birth weight, breech presentation, previous cesarean and premature rupture of membranes were excluded. Intrapartum/neonatal complications were analyzed. Logistic regression was used to calculate adjusted odds ratios, using 39 weeks as reference.311,264 black were compared with 2,451,774 deliveries of other races. For Blacks, the risks of cesarean delivery and intrapartum complications were lower at 38 weeks. Chance of vaginal delivery was greater at 38 weeks. Risks of neonatal complications was not increased at 38 compared to 39 weeks.Intrapartum complications were lower at 38 than at 39 weeks in Blacks with no increased risk of neonatal complications. Meconium staining and fetal distress were higher as early as at 40 weeks, perhaps due to accelerated maturation. While a 39-week goal is simple and benefits many patients, a more "personalized medicine" approach may benefit even more mothers and babies.

Background Although screening and brief intervention (SBI) for unhealthy alcohol use has demonstrated efficacy in some trials, its implementation has been limited. Technology-delivered approaches are a promising alternative, particularly during pregnancy when the importance of alcohol use is amplified. The present trial evaluated the feasibility and acceptability of an interactive, empathic, video-enhanced, and computer-delivered SBI (e-SBI) plus 3 tailored mailings, and estimated intervention effects. Methods We recruited 48 pregnant women who screened positive for alcohol risk at an urban prenatal care clinic. Participants were randomly assigned to the e-SBI plus mailings or to a control session on infant nutrition, and were re-evaluated during their postpartum hospitalization. The primary outcome was 90-day period prevalence abstinence as measured by timeline follow-back interview. Results Participants rated the intervention as easy to use and helpful (4.7 to 5.0 on a 5-point scale). Blinded follow-up evaluation at childbirth revealed medium-size intervention effects on 90-day period prevalence abstinence (OR = 3.4); similarly, intervention effects on a combined healthy pregnancy outcome variable (live birth, normal birthweight, and no neonatal intensive care unit stay) were also of moderate magnitude in favor of e-SBI participants (OR = 3.3). As expected in this intentionally underpowered pilot trial, these effects were nonsignificant (p = 0.19 and 0.09, respectively). Conclusions This pilot trial demonstrated the acceptability and preliminary efficacy of e-SBI plus tailored mailings for alcohol use in pregnancy. These findings mirror the promising results of other trials using a similar approach and should be confirmed in a fully powered trial.

Background Limitations in time and training have hindered widespread implementation of alcohol-based interventions in prenatal clinics. Also, despite the possibility of underreporting or relapse, many at-risk women report that they quit drinking after pregnancy confirmation so that interventions focusing on current drinking may seem unnecessary. The Computerized Brief Intervention for Alcohol Use in Pregnancy (C-BIAP) was designed to (a) be implemented via a handheld device in prenatal clinics, and (b) use a modified brief intervention strategy with women who screen at-risk but report no current drinking. Methods The authors administered the C-BIAP to 18 T-ACE (Tolerance, Annoyance, Cut Down, and Eye Opener)-positive pregnant African American women who provided quantitative and qualitative feedback. Results The C-BIAP received high ratings of acceptability; qualitative feedback was also positive overall and suggested good acceptance of abstinence themes. Conclusions Technology may be a feasible and acceptable method for brief intervention delivery with pregnant women who do not report current drinking.

Objective The benefits of the 39-week rule have been questioned and concerns of increased stillbirth after adoption of this rule have been raised. Whether expectant management risks outweigh the benefits of awaiting 39 weeks has not been studied. We analyze the risks of expectant management at term and the optimal timing for delivery. Study Design All U.S. nonanomalous singleton term deliveries in 2013 were selected, excluding diabetes/hypertension, and low birth weight. Maternal/neonatal complications and stillbirth/infant death were compared among expectant management versus deliveries at each term gestational age. Logistic regression was used to calculate adjust odds ratios of complications according to delivery plan at each gestational age. Results From approximately 3 million deliveries, maternal complications during expectant management were lower at early term, and became higher at 39 weeks, relative risk [RR] (95% confidence interval [CI]) = 1.18 (1.16–1.19). Neonatal complications during expectant management were lower during early term, and became higher at ≥39 weeks, RR (95% CI) = 1.09 (1.08–1.09). The risk of perinatal mortality in the expectant management group was lower during early term, and became higher at ≥39 weeks, 18.93 (17.83–20.10) versus 17.37 (16.61–18.16), p = 0.010. Conclusion Complications during expectant management occurring while awaiting full term do not outweigh the benefits of better outcomes from reaching 39 weeks. However, extending beyond 39 weeks may put these pregnancies at an increased risk.

OBJECTIVE Despite known racial disparities in obstetrics, as well as differences in magnesium pharmacodynamics according to race, the effect of race/ethnicity in magnesium sulfate (MgSO4) use during pregnancy has not been studied. Whether some mothers are at increased risk of side effects, or infants at decreased neuroprotective effects is unknown. We analyze the effect of race/ethnicity in maternal/infant outcomes after MgSO4 neuroprotection. STUDY DESIGN Subgroup analysis of a multicenter clinical trial (BEAM trial) where pregnant women at risk of preterm birth were randomized to either MgSO4 or placebo. For this study, nonanomalous singleton pregnancies were studied. The effect of race in maternal/neonatal outcomes after MgSO4 was analyzed with Breslow-Day and multifactorial ANOVA. Logistic regression was used to calculate odds ratios (OR) of complications according to race. RESULTS 922 MgSO4 and 972 placebo cases were included (45.0% African-American, 36.2% Caucasian, 17.8% Hispanics, and 1.0% Asians). Interaction analysis showed a significant effect of race/ethnicity (p = .043). Hispanics presented the highest frequency (88.3%, p

Objective: Evidence supports the need of dose-adjustment of several drugs according to body mass index (BMI) to prevent toxicity in the underweight, and ensure efficacy in obese women. However, for MgSO4 neuroprotection, the effect of BMI on maternal toxicity and fetal neuroprotection is understudied. We analyze the effect of BMI on maternal/infant outcomes after MgSO4.Methods: Secondary analysis of a clinical trial that studied MgSO4 neuroprotection. Maternal side effects, magnesium cord levels, and offspring cerebral palsy/death were analyzed along BMI strata using ANOVA and chi-square test. Logistic regression was used to calculate adjusted odds ratios according to the treatment and BMI, using nonobese that received placebo as reference. Interaction analyses were performed to validate differential efficacy of BMI.Results: From 2241 women, more side effects and higher magnesium cord levels were seen in underweight women (p = 0.05). MgSO4 neuroprotection was effective in the non-obese (p = 0.02),...

Background Detection of in-pregnancy maternal risk alcohol drinking is an essential first step in preventing fetal alcohol spectrum disorders, and the widely used T-ACE screen was developed for that purpose. We recently reported that increasing the total T-ACE score cut-point from 2 to 3 doubled specificity of detecting risk drinking in pregnancy and identified 4-year-old children with neurobehavioral effects associated with prenatal alcohol exposure. Methods In this study, the TACER-3 was further validated in another prospectively identified high-risk urban cohort. Women were categorized as follows: (i) Not At-Risk Group (negative on T-ACE and TACER-3); (ii) At-Risk Group (positive on T-ACE and TACER-3); and (iii) Change Risk Group (positive on T-ACE but negative on TACER-3). Results The TACER-3 total score cut-point of 3 yielded fewer “false positives” than the T-ACE cut-point of 2. Based on relative risk scores, women in the TACER-3-positive At-Risk Group were more likely to drink alcohol during pregnancy than women in the Change Risk Group. In contrast, women in the Not At-Risk Group were largely not different in their drinking from women in the Change Risk Group. The largest increases in relative risk of the At-Risk Group compared to the Change Risk Group were for the amount of drinking per day across pregnancy (RR = 11.4) and for the amount of drinking per drinking day at the first prenatal visit (RR = 12.7). For both of these measures, the relative risk of at-risk alcohol consumption in the At-Risk Group was over >10 times that of the Change Risk Group. Conclusions Thus, the TACER-3 was more effective at selectively identifying women drinking at fetal risk levels than the original T-ACE. The TACER-3 allows for more efficient use of healthcare provider time in directing targeted clinical interventions with pregnant women identified as drinking at fetal risk levels.

Systems for the provision of healthcare need to be improved, since costs are already high and rising along with the needs of an aging population. In considering evaluations of two programs from opposite ends of the country, inferences can differ depending on the observer. While the demographic-healthcare time bomb we're faced with should have been obvious years ago, the need for positive action is upon us. The difficult issues are not so much errors in the past as they are (1) disingenuous suggestions that this isn't a cost problem, (2) a need to improve team behaviors and functions to increase the value of the care provided (i.e., quality for expenditure), (3) a lack of engagement and enthusiasm by providers for new systems and (4) most importantly, resistance to change brought from outside the care environment and the source and beneficiaries of the change not being primarily the local stakeholders. Care providers and recipients, as well as the governments funding healthcare will need to be convinced that we are successfully increasing healthcare value and improving patient outcomes.

Background To obtain a probability sample of pregnancies, the National Children's Study conducted door-to-door recruitment in randomly selected neighbourhoods in randomly selected counties in 2009–10. In 2011, an experiment was conducted in 10 US counties, in which the two-stage geographic sample was maintained, but participants were recruited in prenatal care provider offices. We describe our experience recruiting pregnant women this way in Wayne County, Michigan, a county where geographically eligible women attended 147 prenatal care settings, and comprised just 2% of total county pregnancies. Methods After screening for address eligibility in prenatal care offices, we used a three-part recruitment process: (1) providers obtained permission for us to contact eligible patients, (2) clinical research staff described the study to women in clinical settings, and (3) survey research staff visited the home to consent and interview eligible women. Results We screened 34 065 addresses in 67 provider settings to find 215 eligible women. Providers obtained permission for research contact from 81.4% of eligible women, of whom 92.5% agreed to a home visit. All home-visited women consented, giving a net enrolment of 75%. From birth certificates, we estimate that 30% of eligible county pregnancies were enrolled, reaching 40–50% in the final recruitment months. Conclusions We recruited a high fraction of pregnancies identified in a broad cross-section of provider offices. Nonetheless, because of time and resource constraints, we could enrol only a fraction of geographically eligible pregnancies. Our experience suggests that the probability sampling of pregnancies for research could be more efficiently achieved through sampling of providers rather than households.

Uterine rupture is a rare but feared perinatal event. Despite abundant research and changes to guidelines implemented to reduce this complication, evaluation of whether uterine rupture still engenders significant maternal/neonatal morbidity has not been conducted. We analyzed recent cases of maternal/neonatal morbidity after uterine rupture.Deliveries complicated by uterine rupture from 2011 to 2012 in the United States were selected. Comparison cases without uterine rupture were used as controls. Measures of maternal/neonatal complications were compared with χFrom 7 922 016 births, 1925 cases of uterine rupture and 3765 controls were identified. Regression models retained four maternal outcomes; blood transfusion was the most common (~15%) and unplanned hysterectomy had the highest odds (~97-fold). For newborns, the model retained three measures of morbidity; neonatal intensive care unit admission was the most common (~35%) and seizures had the highest odds (~20-fold).Despite efforts to reduce complications, mothers remain at significant risk of unplanned hysterectomy and intensive care unit admission. Neonates are at sizeable risk for neonatal intensive care unit admission and seizures, recognized markers of long-term neurobehavioral abnormality. Uterine rupture remains a major risk for mothers and babies.

Introduction: Cervical intraepithelial neoplasia (CIN) is increased in women with systemic lupus erythematosus (SLE). Cervical neoplasia is caused by human papilloma virus (HPV) infection which persists and causes malignant transformation of infected cervical cells. Women with lupus have impaired immune systems which can facilitate HPV persistence. We hypothesized that women with SLE who developed CIN would be younger, have more severe disease and received more immunosuppressive treatment. To test this hypothesis, a case-control study was conducted focusing on two key variables, SLE disease severity and immunosuppressive treatment, which we believed would be the major determinants of CIN development in SLE. Methods: A case control analysis was performed to compare the clinical characteristics of SLE women with cervical neoplasia (cases) to SLE women without cervical neoplasia (controls). Formalin fixed blocks of neoplastic cervical tissue were obtained from 113 women with SLE and tissue histology confirmed by 2 pathologists. Clinical data was obtained by retrospective chart reviews. Logistic regression was used to evaluate for any significant differences in clinical variables between the cases and the controls. Two sets of controls were used for comparison with a 2:1 match for each control group to cases group. Results: Using matched controls adjusting for age and race, logistic regression analysis showed no significant difference between cases and controls for any of the clinical variables. In particular, there were no significant differences between cases vs. matched and vs. unmatched controls for factors related to SLE (disease severity, use of immunosuppressive drugs), chronic metabolic diseases (hypertension, diabetes) and HPV risk factors (marital status, smoking, gravidity parity). Conclusion: The key finding of this study is that SLE patients who develop CIN are not clinically different from SLE patients who do not develop CIN. Thus, lupus disease severity and immunosuppressive treatment were not susceptibility factors for CIN in our female lupus cohort.

Ethyl Glucoronide (EtG) and Ethyl Sulfate (EtS) have shown promise as biomarkers for alcohol and may be sensitive enough for use with pregnant women in whom even low-level alcohol use is important. However, there have been reports of over-sensitivity of EtG and EtS to incidental exposure to sources such as alcohol-based hand sanitizer. Further, few studies have evaluated these biomarkers among pregnant women, in whom the dynamics of these metabolites may differ.This study evaluated whether commercial EtG-EtS testing was vulnerable to high levels of environmental exposure to alcohol in pregnant women.Two separate samples of five nurses-one pregnant and the other postpartum, all of whom reported high levels of alcohol-based hand sanitizer use-provided urine samples before and 4-8 hours after rinsing with alcohol-based mouthwash and using hand sanitizer. The five pregnant nurses provided urine samples before, during, and after an 8-hour nursing shift, during which they repeatedly cleansed with alcohol-based hand sanitizer (mean 33.8 uses). The five postpartum nurses used hand sanitizer repeatedly between baseline and follow-up urine samples.No urine samples were positive for EtG-EtS at baseline or follow-up, despite use of mouthwash and-in the pregnant sample-heavy use of hand sanitizer (mean of 33.8 uses) throughout the 8-hour shift.Current, commercially available EtG-EtS testing does not appear vulnerable to even heavy exposure to incidental sources of alcohol among pregnant and postpartum women.

Alcohol consumption during pregnancy is one potential risk factor for spontaneous abortion (SAb). Prior research suggested that heavy drinking during pregnancy was associated with significantly increased rates of SAb, but results for lower levels of drinking have been inconsistent. We examined the association between different levels and patterns of prenatal alcohol consumption and SAb in a high-risk inner-city sample. We hypothesized that higher levels, binge patterns, and more frequent drinking would be associated with increased rates of SAb. The quantity and frequency of self-reported peri-conceptional and repeated in-pregnancy maternal drinking volumes per beverage type were assessed with semi-structured interviews in a prospective subsample of 302 African-American mothers. Relations between various measures of prenatal alcohol exposure and SAb were assessed using logistic regression. After controlling for various potential confounders, there was a significant positive relation between average absolute alcohol use per day across pregnancy and SAb. Greater frequency of drinking episodes also predicted SAb: an average of even one day of drinking per week across pregnancy was associated with an increase in the incidence of SAb. However, contrary to our hypothesis, neither the amount of alcohol drunk per drinking day nor a measure of binge drinking were significantly related to SAb after controlling for confounders. Differences in when women who drank at risk levels initiated antenatal care may have under-estimated the impact of alcohol on SAb in this low-SES urban African American sample. Some drinking measures averaged across pregnancy may have underestimated consumption and overestimated risk of SAb, but others risk-drinking measures that avoid this limitation show similar relations to SAb. Identifying fetal risk drinking in pregnant women is critical to increasing the effectiveness of interventions that reduce risk-level alcohol consumption and protect from pregnancy loss.

Drinking alcohol during pregnancy has a range of negative consequences for the developing fetus. Screening and brief intervention approaches have significant promise, but their population impact may be limited by a range of challenges to implementation. We, therefore, conducted preliminary acceptability and feasibility evaluation of a computer-delivered brief intervention for alcohol use during pregnancy.Participants were 50 pregnant women who screened positive for risky drinking during a routine prenatal clinic visit and were randomly assigned to computer-delivered brief intervention or assessment-only conditions.Ratings of intervention ease of use, helpfulness, and other factors were high (4.7-5.0 on a 1-5 scale). Participants in both conditions significantly decreased alcohol use at follow-up, with no group differences; however, birth weights for infants born to women in the intervention group were significantly higher (p0.05, d = 0.62).Further development and study of computer-delivered screening and intervention for alcohol use during pregnancy are warranted.

Detecting patterns of maternal drinking that place fetuses at risk for fetal alcohol spectrum disorders (FASDs) is critical to diagnosis, treatment, and prevention but is challenging because information on antenatal drinking collected during pregnancy is often insufficient or lacking. Although retrospective assessments have been considered less favored by many researchers due to presumed poor reliability, this perception may be inaccurate because of reduced maternal denial and/or distortion. The present study hypothesized that fetal alcohol exposure, as assessed retrospectively during child adolescence, would be related significantly to prior measures of maternal drinking and would predict alcohol-related behavioral problems in teens better than antenatal measures of maternal alcohol consumption. Drinking was assessed during pregnancy, and retrospectively about the same pregnancy, at a 14-year follow-up in 288 African-American women using well-validated semistructured interviews. Regression analysis examined the predictive validity of both drinking assessments on pregnancy outcomes and on teacher-reported teen behavior outcomes. Retrospective maternal self-reported drinking assessed 14 years postpartum was significantly higher than antenatal reports of consumption. Retrospective report identified 10.8 times more women as risk drinkers (≥ one drink per day) than the antenatal report. Antenatal and retrospective reports were moderately correlated and both were correlated with the Michigan Alcoholism Screening Test. Self-reported alcohol consumption during pregnancy based on retrospective report identified significantly more teens exposed prenatally to at-risk alcohol levels than antenatal, in-pregnancy reports. Retrospective report predicted more teen behavior problems (e.g., attention problems and externalizing behaviors) than the antenatal report. Antenatal report predicted younger gestational age at birth and retrospective report predicted smaller birth size; neither predicted teen IQ. These results suggest that if only antenatal, in-pregnancy maternal report is used, then a substantial proportion of children exposed prenatally to risk levels of alcohol might be misclassified. The validity of retrospective assessment of prior drinking during pregnancy as a more effective indicator of prenatal exposure was established by predicting more behavioral problems in teens than antenatal report. Retrospective report can provide valid information about drinking during a prior pregnancy and may facilitate diagnosis and subsequent interventions by educators, social service personnel, and health-care providers, thereby reducing the life-long impact of FASDs.